Pediatric Guidelines: Fever in Oncology and BMT Patients - Fever and Neutropenia

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High-Risk Fever and Neutropenia: Patients with ANY of the following: hematologic malignancy in induction, consolidation or delayed intensification phase of therapy, hematologic malignancy with relapsed or persistent disease, neutropenia anticipated to last > 7 days, significant mucositis, BMT patients before neutrophil engraftment, focus of serious bacterial infection identified (e.g. pneumonia, abscess).

Low-Risk Fever and Neutropenia: Patients with NO High-Risk criteria AND ALL of the following: neutropenia anticipated to last < 7 days, clinically well-appearing, no focus of serious bacterial infection.

Clinically Unstable: ANY of the following: shaking chills or rigors, hypotension, hypothermia, abnormal pulses or capillary refill, respiratory distress or hypoxia, altered mental status, tachycardia out of proportion to fever. 

These guidelines are specific to patients whose neutropenia is related to chemotherapy or BMT conditioning and may not be appropriate for patients with neutropenia due to other causes. 

Please refer to the following guidelines for further details:

Pediatric Oncology and BMT Patients with Fever: Emergency Department Managment

Inpatient Management of Pediatric Oncology and BMT Patients with Fever

 Condition Major Pathogens   First Choice Therapy  Alternative Therapy  Comments
Fever and neutropenia, High-Risk, clinically stable 

Gram positive: 

Viridans group streptococci

Coagulase-negative staphylococci

Staphylococcus aureus

Gram negative:

Enteric Gram negatives

Hospital-acquired Gram negatives including Pseudomonas

 

Cefepime 50mg/kg/dose IV q8h (max 2g/dose) monotherapy

ADD Vancomycin 15mg/kg/dose IV q6-8h (initial max 1g/dose) if findings concerning for infection at central line site, or other Gram positive infection 

Consider Metronidazole 10mg/kg/dose IV q8h (max 500mg/dose) for suspected intra-abdominal infection

 

Non-severe cephalosporin allergy:

Piperacillin-tazobactam (Zosyn) 100mg/kg/dose piperacillin IV q6h (max 4g piperacillin/dose)

 

Click here for guidelines on modfication of therapy 

Severe beta lactam allergy:

Aztreonam 30mg/kg/dose IV q8h (max 2g/dose)

AND

Vancomycin 15mg/kg/dose IV q6-8h (initial max 1g/dose)

Fever and neutropenia, High-Risk, clinically unstable, but not with severe sepsis*    Similar  

Cefepime 50mg/kg/dose IV q8h (max 2g/dose)

AND 

Vancomycin 15mg/kg/dose IV q6-8h (initial max 1g/dose)

AND 

Ciprofloxacin 15mg/kg/dose IV q12h (max 400mg/dose IV q8h) 

Consider: Metronidazole 10mg/kg/dose IV q8h (max 500mg/dose) for suspected intra-abdominal infection

  

Non-severe cephalosporin allergy:

Substitute Piperacillin-tazobactam (Zosyn) 100mg/kg/dose piperacillin IV q6h (max 4g piperacillin/dose) for Cefepime

Piperacillin-tazobactam has anaerobic activity so do not need concurrent Metronidazole for anaerobic infection

Vancomycin and Ciprofloxacin may be discontinued if cultures are negative for resistant Gram positive or Gram negative organisms

Click here for guidelines on modification of therapy

*Refer to Severe Sepsis section for patients with fever and neutropenia who develop severe sepsis

 

  

Severe beta lactam allergy:

Substitute Aztreonam 30mg/kg/dose IV q8h (max 2g/dose) for Cefepime

ADD Vancomycin 15mg/kg/dose IV q6-8h (initial max 1g/dose) 

AND Ciprofloxacin 15mg/kg/dose IV q12h (max 400mg/dose IV q8h) for both above regimens

Fever and neutropenia, Low-Risk  Similar - lower risk of bacteremia 

Inpatient:

Ceftazidime 50mg/kg/dose IV q8h (max 2g/dose)

Non-severe cephalosporin allergy:

Piperacillin-tazobactam (Zosyn) 100mg/kg/dose piperacillin IV q6h (max 4g piperacillin/dose)

If patient is clinically unstable or has identified serious infectious source, use High-Risk guidelines

Click here for guidelines on modification of therapy

 

ED: 

Cefepime or Ceftriaxone per ED pathway

Severe beta lactam allergy

Aztreonam 30mg/kg/dose IV q8h (max 2g/dose)

Reference: Lehrnbecher T, et al. Guideline for management of fever and neutropenia in children with cancer and/or undergoing hematopoeitic stem-cell transplantationJ Clin Oncol 2012;30:4427-4438.

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP).